This is a blog by a former CEO of a large Boston hospital to share thoughts about hospitals, medicine, and health care issues.

Monday, July 21, 2008

Guide to Just Decisions About Behavior

To follow up on our conversations belowabout punishment and discipline following medical errors, we have been experimenting with the scale above as a guide. Let me know what you think about it, particularly the gray area in the middle in which case-by-case discretion is employed. (If you click on the image above, your computer will make it larger and you wil be able to read the categories more clearly.)

9 comments:

Ellen
said...

I would agree with most of this scale, expect that non-participation with patient safety initiatives, in my mind, is equivalent with interfering with the reporting process. Perhaps the discipline is not severe, but the typical example of a clinician who is "too busy" to participate in training (for example), needs to be confronted. Would you agree?

I am going to need to think about punishment slide a bit more..but in the mean time may I say the following:

It is impressive to see a CEO of an institution leading this type of work in the first place, it even more impressive to lead it in such a visible and consistent way vai your blog almost dailt, then even more impressive to tackle the wrong side issue so openly and thoughtfully.

This is such a tangible example of what great leadership is all about..it is very inspiring..Jim Collins may need to add a level 6 to his scoring system..you and Don Berwick can become its first members!

"Failure to participate in a pateint safety initiative" does not belong in the gray area. Many of these initiatives are set up to avoid rare events. Individual perception of risk for these events varies and therefore so will the compliance if it is not built into the culture as mandatory. Why should one by "allowed" to potentially not participate in an initiative? Doesn't this undermine the validity and importance of the patient safety movement?

"Carelessness in providing patient care..." is worse to me than "Near miss or error..." I suppose it depends upon individual judgment, which clearly varies. The reason I find it worse is that I view attitude as more significant than outcome. If you look first at outcome, then yeah, the order is probably correct.

I want to commend you on providing the world with a look at the very complex, challenging world of patient safety. It's easy to throw words like, safety, blame-free, culture, quality and satisfaction around when hospital administrators trying to engage all parties in patient safety initiative within a hospital environment. It all sounds so simple....step back, take a breath, say the words "Time Out" out loud, do the "5 rights" for medication administration, check an arm band to identify the correct patient, these simple things will save patients lives. Your open and frank discussion of this breach in patient safety has served to stimulate a dialogue that is long overdue. I think you have very eloquently provided a glimpse into the complexities that surround the hospital environment today. On the face of it, these patient safety activities seem to be simple. What could be simpler than checking a patient’s armband or asking them what type of procedure they are having or asking all in the room to agree on the type of procedure? These activities will indeed save patients lives, most of the time, if we worked in an environment without distractions that allowed us to focus on only one thing at a time. I have worked as a critical care nurse in hospitals for over 25 years and know that this issue is much more complex than many would like to believe. We work in an environment where the results are rewarded much more than the behaviors. What are your outcomes? What’s your rate of compliance with xyz, an indicator of quality? I have recently been reading the book Influencer by Kerry Patterson et al. In their chapter on designing rewards and demanding accountability, they spend some time discussing two of the issues at hand here. What are the vital behaviors that are required to support a safe patient environment? Are the reward systems designed to acknowledge those vital behaviors or the results? In this case, do we create an environment that looks at and rewards 100% compliance with procedural “time outs” as documented on paper, or does it reward the observed behaviors of marking, “time outs,” and so on. In regards to the discussion on punishments, would punishing the physician and OR staff equate to positive reinforcement of the vital behaviors? As others have said, punishment might lead to a temporary change in behavior but it is unlikely to support a long term change in behavior. The use of punishment in a situation such as this might invite a more emotional response from those involved and those who are supportive of the individuals. I’m not saying that riots would ensue but there are definite, significant ramifications of the use of punishment. I applaud you for your open, frank presentation of the facts and your thought processes behind your response. I have worked with many hospital administrators that would do well to learn from you, someone who seems to “walk the talk.”

I'm going to play the devil's advocate to Mary Pat's comments about punishment and say that punishment, or the lack of it, is sometimes used to send a message, not only to the people involved but to the rest of the staff. It makes a statement about what leadership's expectations are for performance and adherence to procedure and how consistent they are in applying their expectations to everyone.

Applying the chart to the case under discussion, by my interpretation it belongs squarely in the gray area, and the answer to one of the 3 questions is "yes." (e.g. not performing the timeout undermined patient safety initiatives.) So now what? And does one look at the OR team as a whole when applying this chart, or as individuals? I will be interested in how you handle it; I have no preconceived notions.

I would also apply this chart to the underlying second error that allowed the wrong side to be the one presented for operation, whatever that error may be. In other words, if everything had gone well up to that point, the timeout wouldn't have caught anything. Any info yet on what that original error was?

Thanks for the time and effort on this prolonged discussion, Paul. I agree with all the kudos in the various comments. Hopefully you are inspiring other CEO's......

You've rightfully highlighted that repeated violations of hospital policy would merit discipline. So did anyone ask the surgeon in question whether he has previously skipped the timeout policy? Its hard to believe that his first error happened to be on the case that led to an actual error. Possible, but not likely.

So who has asked him about prior misses? Assuming they exist, what is the justification for not disciplining him?

Paul, I appreciate the scale you've shared about Just Decisions. Where would your team place "no call out"? "Carelessness..." in the gray area or "Reckless..." in the discipline area? It's hard to categorize where there is a serious failure to adhere; no intention to disregard; and a commitment to "blame" process not people. Marie

Our hospital is beginning to implement the "Just Culture" model. Their algorithm is in-depth and recognizes humans make errors, are prone to "at-risk" behaviors (i.e. drift from established protocols), and are sometimes reckless.

Depending on the circumstances the algorithm suggests do nothing, consolation, coaching, or discipline. I'm excited to have a single model for all managers to use so the expectations for staff are clear at all times.